Inefficient anesthesia services are often the result of the way a care model is implemented rather than the model itself.
Detroit Medical Center is a case in point. The multi-location academic medical center uses a care-team model in which anesthesiologists supervise the patient care provided by certified registered nurse anesthetists and anesthesiology residents.
The CRNAs or residents typically remain in a surgical room throughout a procedure, while the attending anesthesiologists oversee multiple procedures concurrently. The ratio of anesthesiologists to CRNAs ranges from 1:2 to 1:4, depending on the acuity of the cases involved. The ratio of attending anesthesiologists to residents is 1:2.
As the DMC also has a CRNA training program, CRNA students are involved in some patient cases too, working alongside practicing CRNAs.
To work well, this care model relies on teamwork and communication from strong leadership. But that wasn’t happening consistently at DMC for two primary reasons:
- Separate entities. DMC managed the CRNAs as a hospital department, while the physician anesthesiologists were members of a private medical group that provided anesthesia services under a contract with DMC.
- Turf battles. The culture emphasized competition—not cooperation—between anesthesiologists and CRNAs.
“Getting the two groups to work together or to see eye-to-eye on any issue was difficult. Communication was poor,” recalls Vinay Pallekonda, M.D., an anesthesiologist, 4 ½-year veteran of DMC, assistant professor at Wayne State University and regional medical director for NorthStar Anesthesia. Dr. Pallekonda was part of the new leadership team given the opportunity to improve the situation.
This situation led to inefficient service delivery, such as when CRNAs and anesthesiologists both collected information from patients on their medical histories. “Patients were getting multiple people coming in and asking them the same questions,” Dr. Pallekonda said.
To improve the efficiency and quality of anesthesia services at multiple campuses, DMC signed a five-year contract, beginning on July 1, 2015, with NorthStar Anesthesia to oversee anesthesia operations at four acute-care hospitals, a cardiovascular institute and three ambulatory surgery centers.
NorthStar, which manages anesthesia services at more than 180 facilities in 21 states, is adept at different care-team models, ranging from those made up of all anesthesiologists to others made up of all CRNAs.
We defined what the expectations are very clearly from the get-go. We communicate these definitions across the whole care team, and we hold people accountable for what the expectations are.
Tapping into its experience managing transitions, NorthStar introduced DMC’s 50 anesthesiologists and 120 CRNAs to NorthStar’s culture, which emphasizes teamwork, communication and performance measurement. A new leadership team was identified to oversee the changes necessary to run more efficiently. NorthStar elevated key personnel to positions that were accountable for keeping these values upheld. Through NorthStar University, extensive training on the company, team leadership management, business management and medical practice management, allowed team members an opportunity to lead this group effectively through what can be a challenging transition.
It also introduced them to a community of clinicians who had experienced similar transitions and were available to leverage best practices and share successes to implement at their own facility. To nurture its culture, NorthStar employs all of the anesthesiologists and CRNAs working at its sites. It also uses a dual anesthesiologist-CRNA management structure in which medical directors and chief CRNAs collaborate at four levels: a site level; immediate regional level; larger regional level like the Midwest ; and national level, where the chief medical officer and the chief anesthetist officer oversee clinical procedures, policies and performance metrics.
NorthStar also made concrete changes in the way anesthesiologists and CRNAs collaborate. For example, one person—either an anesthesiologist, medical resident or CRNA—now completes each patient’s medical history and physical exam and enters the information into the electronic health records system. The team members assigned to the case then develop an anesthesia plan together based on the surgical or diagnostic procedure, medical history, and other factors.
Getting the two groups to work together or to see eye-to-eye on any issue was difficult. Communication was poor.
-Vinay Pallekonda, M.D., Regional Medical Director, NorthStar Anesthesia
Communication among all geographic levels and job functions is focused and direct. “We defined what the expectations are very clearly from the get-go. We communicate these definitions across the whole care team, and we hold people accountable for what the expectations are,” Dr. Pallekonda says.
Regular meetings also enhance communication and teamwork. For example, medical directors at each of DMC’s facilities participate in a weekly conference call that also includes Dr. Pallekonda and NorthStar’s Chief Medical Officer Brian Woods, M.D. Dr. Pallekonda meets regularly with the regional chief CRNA, who is his counterpart at DMC, as well as with DMC’s executives and surgeons.
To assess the performance of the anesthesia services under its command, NorthStar tracks clinical and operational metrics and shares the results regularly with its employees and DMC’s executive team. Examples of metrics include: Delays in the start time of each day’s first surgery case that are caused by anesthesiology; and the minutes of anesthesiology “ready time” after a patient is wheeled into a surgery room. DMC already has seen improvement on these two measures of anesthesia service performance as well as others, according to Dr. Pallekonda.
“At the DMC, people have done the same thing for many years, and a lot of personalities are resistant to change,” Dr. Pallekonda says. He credits NorthStar’s experience in managing transitions for its success in overcoming DMC’s historical barriers and implementing a lasting cultural change. The timing to implement this cultural change exceeded expectations of all parties involved.